You get a patient in triage with an anterior shoulder dislocation that happened 10 minutes prior to arrival. It’s happened to him multiple times on the same shoulder and all he did to dislocate it was to push up from a chair. You really want to get it reduced quickly because you are smart enough to know, the quicker you pop it in, the smoother the reduction goes. But shoot, you remember someone told you that for every reduction, you need a pre-reduction xray before you can do anything to it. What do you do?
What purpose does getting a pre-reduction film serve?
1) To rule out any fractures that came with the dislocation. Is there a decision rule for this?
2) To make sure that your reduction didn’t cause a fracture. No way around this one.
To address the first issue, a group in Quebec developed the Quebec shoulder dislocation rule in an effort to help with exactly this issue. (M. Emond, N. Le Sage, A. Lavoie, and L. Moore, “Refinement of the Quebec decision rule for radiography in shoulder dislocation.”, CJEM, 2009.)
To apply the rule, the patient needs to have a GCS 15.
However, this study failed validation in an Australian study so although this helps as a guide, it shouldn’t be used as a hard and fast rule.
Additionally, a 2011 retrospective study (Orloski J, Eskin B, Allegra PC, Allegra JR. “Do all patients with shoulder dislocations need prereduction x-rays?” Am J Emerg Med. 2011 Jul;29(6):609-12.) showed that less than 1% of their patients with shoulder dislocations had a fracture. This is reassuring but the study never addressed whether or not all patients studied received pre-reduction xrays which could have increased the percentage of fractures due to completely missed diagnoses.
So unfortunately, there is no validated decision rule to help you out at this point. If you want to take a chance (a very good chance), if it’s a non-traumatic, recurrent dislocation in a patient <40 years of age without ecchymosis, you could consider not getting a pre-reduction xray. But if you really want to play it by the book and save yourself a headache in the case that the post reduction film shows a fracture, you should probably stick to the old ways of getting pre-reduction films on everyone.